Malignant anal tumours

HIV-positive patients with anal carcinoma have poorer treatment tolerance and outcome than HIV-negative patients

PURPOSE

Anal carcinoma is being found in HIV-positive patients with increasing frequency. Most patients are treated with combined chemotherapy and radiation. It was our impression that HIV-positive patients do not fare as well as HIV-negative patients in terms of both response to and tolerance of therapy.

METHODS

To test this hypothesis, we reviewed our experience with anal carcinoma and compared HIV-positive to HIV-negative patients by age, gender, sexual orientation, stage at diagnosis, treatment rendered, response to treatment, tolerance, and survival. From 1985 to 1998, 98 patients with anal neoplasms were treated. Seventy-three patients had invasive squamous-cell carcinoma (including cloacogenic carcinoma), and this cohort was analyzed. Thirteen patients were HIV positive and 60 were HIV negative.

RESULTS

The HIV-positive and HIV-negative groups differed significantly by age (42 vs. 62 years, P < 0.001), male gender (92 vs. 42 percent, P < 0.001), and homosexuality (46 vs. 15 percent, P < 0.05). There were no differences by stage at diagnosis or radiation dose received. Acute treatment major toxicity differed significantly (HIV positive 80 percent vs. HIV negative 30 percent; P < 0.005). Only 62 percent of HIV-positive patients were rendered disease free after initial therapy vs. 85 percent of HIV-negative patients (P = 0.11). Median time to cancer-related death was 1.4 vs. 5.3 years (P < 0.05). A survival model did not show age, gender, stage, or treatment to be independent predictors.

CONCLUSION

We found that HIV-positive patients with anal carcinoma seem to be a different population from HIV-negative patients by age, gender, and sexual orientation. They have a poorer tolerance for combined therapy and a shorter time to cancer-related death. A strong trend to poorer initial response rate was also seen. These results suggest that the treatment of HIV-positive patients with anal carcinoma needs to be reassessed.

Anorectal injury following pelvic radiotherapy

BACKGROUND

Current knowledge of the effects of radiation on the anorectum is based on a limited number of studies. Variability in delivery techniques, both currently and historically, combined with a paucity of prospective and randomized studies makes interpretation of the literature difficult. This review presents the existing evidence and identifies areas that require further work.

METHODS

This review is based on a literature search (Medline and PubMed) and manual cross-referencing.

RESULTS AND CONCLUSION

More than three-quarters of patients receiving pelvic radiotherapy experience acute anorectal symptoms and up to one-fifth suffer from late-phase radiation proctitis. About 5 per cent develop other chronic complications, such as fistula, stricture and disabling faecal incontinence. The risk of rectal cancer may be increased. Conservative treatment options are of limited value. Surgery may be considered if symptoms are severe, provided sphincter function is adequate and recurrent disease is excluded. Large prospective studies with accurate dosimetric data and long-term follow-up are needed to provide meaningful information on which to base new strategies to minimize the side-effects from radiotherapy.

Anal Carcinoma

Carcinoma of the anus is a rare malignancy that usually is diagnosed at an advanced stage, in spite of being easily visible and accessible. Its treatment has evolved from being mainly surgical to one consisting of chemotherapy (with fluorouracil and mitomycin) and radiation (megavoltage linear accelerator therapy delivering between 40 to 50 Gy). Local surgical excision is most often performed for either carcinoma in situ or microinvasive lesions of the anal margin. Radical resection is indicated for patients with residual disease following chemoradiation or for recurrent disease.

Anorectal manifestations of sexually transmitted infections

Sexually transmitted infections have a wide range of clinical presentations, including involvement of the anal verge, anal canal and rectum. This review focuses on anorectal sexually transmitted infections which may cause diagnostic difficulty when encountered by the coloproctologist. An approach to the diagnosis of a variety of sexually transmitted infections is set out, with a discussion of the role of biopsy and a summary of relevant histopathological findings. The value of early antibiotic treatment is discussed. Problems related to HIV/AIDS are highlighted, as clinical presentation may be atypical in immunosuppressed individuals. Sexually transmitted oncogenic viruses and their role in anal neoplasia are also briefly summarized.

Anal Duct Carcinoma: Case Report and Review of the Literature

This report details the clinical course of two patients with true anal duct carcinoma. The incidence of this malignancy is low. The tissues of origination are the glands of the anal duct. The features that differentiate this tumor from the usual rectal carcinoma are prominent ductal structures, abundant mucin production with organized mucinous pools, and infiltration into the perirectal soft tissue. The clinical management of anal duct carcinoma remains a surgical challenge. The extent of surgical resection must be radical because of the infiltrative nature of the tumor. This report describes treatment of two patients with anal duct carcinoma. The first patient was a black woman with no previous history of rectal disease. Her operative procedure was an abdominoperineal resection with posterior vaginectomy. Nine months after initial surgery a local recurrence was resected. The second patient was a white man with a previous history of hemorrhoidectomy and anal fissure. He underwent an abdominoperineal resection but had positive dermal skin margins on permanent sections despite wide perirectal soft tissue resection. A secondary resection with confirmed clear margins of the skin was performed 2 weeks postoperatively. One management aspect of anal duct carcinoma that needs emphasis is the need for wide local excision of the perirectal soft tissues.

Treatment Options for Perianal Bowen's Disease: Survey of American Society of Colon and Rectal Surgeons Members

The aim of this study was to determine current management practices of physicians caring for patients with perianal Bowen's disease. A questionnaire was sent to 1499 members listed in the 1997 American Society of Colon and Rectal Surgeons Directory asking them how many patients they have treated and which operative or nonoperative treatment option they choose for small (≤3 cm), large (> 3 cm), and microscopic lesions. Of 1499, 663 (44.2%) surgeons responded. Not all respondents answered each item. Seventy-five per cent of surgeons surveyed (n = 653) devote greater than 75 per cent of their practice to colon and rectal surgery. Of 642 respondents, 552 (86%) managed a total of <10 patients, and 90/642 (14%), ≥10 patients. Ninety-six per cent of respondents use wide local excision for patients with small lesions. Eighty-seven per cent of respondents use wide local excision for patients with large lesions. Seventy-four per cent treat patients with microscopic disease conservatively and without wide excision. The majority of surgeons caring for patients with perianal Bowen's disease are performing wide local excision for both small and large lesions. Microscopic disease was usually treated conservatively with observation alone.

Perianal Bowen's disease and anal intraepithelial neoplasia: review of the literature

PURPOSE

The aim of this study was to review the literature with regard to perianal Bowen's disease and anal intraepithelial neoplasia.

METHODS

A literature review was conducted from 1960 to 1999 using MEDLINE.

RESULTS

Perianal Bowen's disease and anal intraepithelial neoplasia are precursors to squamous carcinoma of the anus. They are analogous to and are associated with cervical and vulvar intraepithelial neoplasia, and have human papillomavirus as a common cause. Biopsy and histopathologic examination is required for diagnosis and to distinguish other perianal dermatoses. Treatment options range from aggressive wide local excision of all disease with negative margins to observation alone for microscopic lesions not visible to the naked eye. The disease has a proclivity for recurrence and recalcitrance.

CONCLUSIONS

Most surgeons caring for patients with perianal Bowen's disease and high-grade anal epithelial neoplasia use wide local excision, with an effort to obtain disease-free margins. Some authors have reported the advantages of ablative procedures such as laser ablation and cryotherapy. Microscopic disease found serendipitously in hemorrhoidectomy specimens can probably be treated conservatively with serial examinations alone. There is a lack of controlled data supporting an optimal treatment strategy. A multicenter controlled study comparing wide local excision with ablative procedures may be warranted.

Malignant tumors of the anal canal: the spectrum of disease, treatment, and outcomes

BACKGROUND

Cancers of the anal canal are a rare and diverse group of tumors of the gastrointestinal tract currently managed most often with surgery, chemoradiotherapy, or both. Previous investigations of cancer of the anal canal have reported on small numbers of patients, included only squamous histology, or included a select group of patients. The current study reviewed a large consecutive series of patients with cancer of the anal canal, including all histologies, who received chemoradiotherapy as the primary treatment modality.

METHODS

The spectrum of pathology, treatment, and outcomes for 192 patients with malignant tumors of the anal canal over a 10-year period, from 1984 to 1994, was analyzed. Patient charts were reviewed for diagnosis, staging, treatment, survival, and recurrence rates.

RESULTS

The pathologies of 192 patients (mean age, 58 years; 119 females and 73 males) included 143 (74%) with squamous cell carcinoma, 36 (19%) with adenocarcinoma, and 7 (4%) with melanoma. The remaining 6 patients (3%) were diagnosed with neuroendocrine tumors (2), carcinoid tumor (1), Kaposi sarcoma (1), leiomyosarcoma (1), or lymphoma (1). T classification distributions were T1 (3%), T2 (46%), T3 (28%), and T4 (12%). The overall crude 5-year survival and recurrence rates were 53% and 34%, respectively. Five-year survival rates were 57% for squamous cell carcinoma, 63% for adenocarcinoma, and 33% for melanoma. Five-year survival rates by T classification were T1 (62%), T2 (57%), T3 (45%), and T4 (17%). Twenty-one (15%) of the patients with squamous cell carcinoma underwent surgical therapy only, with a 5-year survival rate of 60% and a recurrence rate of 23% at 5 years. The remaining 122 patients (85%) with squamous cell carcinoma received chemoradiotherapy only, with a 5-year survival rate of 55% and a recurrence rate of 34% at 5 years. Salvage abdominal perineal resection for recurrent or persistent squamous cell carcinoma after chemoradiotherapy was performed on 13 patients, with 8 (62%) of them alive at a mean follow-up of 32 months. Twenty-two patients (61%) with adenocarcinoma of the anal canal were treated with surgery, and 14 patients (39%) underwent surgery with adjuvant chemoradiation therapy. The 5-year survival and recurrence rates were 63% and 21%, respectively.

CONCLUSIONS

Chemoradiotherapy for patients with squamous cell carcinoma offers survival rates equivalent to surgical therapy and preserved sphincter function. Adenocarcinoma managed with surgery, with adjuvant therapy for selected patients, gives good results. Melanoma continues to be associated with a poor prognosis.

Pulsed dose rate (PDR) brachytherapy of anal carcinoma

BACKGROUND AND PURPOSE

With radiotherapy of anal carcinomas, sphincter preservation can be obtained at survival rates similar to those obtained with radical surgery. By combining external beam irradiation with interstitial irradiation, superiority over standard external irradiation has been obtained. With the introduction of pulsed dose rate equipment, where a single high activity source moves through catheters, a more individualized dose distribution and a further elimination of radiation exposure to the staff can be achieved.

MATERIALS AND METHODS

Between June 1993 and November 1994, 17 patients with anal carcinoma (T1:4, T2:4, T3:6, T4:3) have been treated at the Finsen Center. The treatment consisted of three-field external irradiation 46 Gy/23 fractions with five fractions a week to the anal canal and regional pelvic lymph nodes. Seven to 33 days after completion of external irradiation, the tumorspace was given 25.2 Gy PDR brachytherapy with 42 pulses of 0.6 Gy, one pulse every hour.

RESULTS

One isolated local recurrence has been noted 13 weeks after implantation. One additional local recurrence was seen in a patient with concomitant hepatic and inguinal recurrence. In three patients inguinal recurrence had occurred, two of these patients were irradiated without any further evidence of disease, and one patient with a primary advanced tumour, had local failure. So far necrosis has been observed in 13 patients within 1-49 weeks (median 16 weeks) after implantation. Eight of these patients required colostomy. No relation was observed between the number of implanted needles and the occurrence of necrosis.

CONCLUSIONS

The results indicate that the treatment is highly effective, but with substantial toxicity.

Anorectal disorders

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.

Malignant anal tumours in the Chinese population in Hong Kong

Malignant anal tumours are rare cancers but are particularly common in Switzerland, Poland and Brazil. Very little is known about this condition in the Chinese population. A retrospective study, covering an 11-year period, was performed. A total of 18 patients were treated at the Prince of Wales Hospital, Hong Kong. There were eight squamous cell carcinomas, seven adenocarcinomas and one each of adenosquamous carcinoma, malignant melanoma and leiomyosarcoma. Bleeding per rectum, with or without perianal pain, was the main presenting symptom. Abdominoperineal resection was the treatment modality used in most cases. Adenocarcinomas, seen mainly in males, accounted for about 39% of cases, a figure much higher than that published elsewhere. Another 44% of patients, predominantly females, had squamous cell carcinoma. None had a positive past history of sexually transmitted disease. The local prevalence of HPV infection is much lower than in the Western world, and the role of HPV in the oncogenesis of anal tumours in the Chinese population awaits elucidation.